Healthcare Provider Details

I. General information

NPI: 1881875862
Provider Name (Legal Business Name): NISHA JAIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17742 PRESTON RD
DALLAS TX
75252-6199
US

IV. Provider business mailing address

17742 PRESTON RD
DALLAS TX
75252-6199
US

V. Phone/Fax

Practice location:
  • Phone: 972-702-7546
  • Fax: 214-975-3961
Mailing address:
  • Phone: 972-702-7546
  • Fax: 214-975-3961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM1789
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM1789
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberM1789
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberM1789
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberM1789
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberM1789
License Number StateTX
# 7
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberM1789
License Number StateTX
# 8
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberM1789
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: